Provider Demographics
NPI:1912411273
Name:JOHNSON, CHANEL GEORGETTE (LPC)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:GEORGETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 BEACONSFIELD AVE APT 2N
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1087
Mailing Address - Country:US
Mailing Address - Phone:586-359-5269
Mailing Address - Fax:
Practice Address - Street 1:44899 CENTRE CT STE 101
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-792-1654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-24
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016390101YP2500X
MI6401018436101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional